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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS J 7 e'Te?-' r�, _ 't c�>�T f�-- c--�4 s4—j :54E� - CITVIZIP _CST o Z�Y n1 �l Z 1 0 CROSS STREET APN 13 {]�dd6 I l-'ti+I 003PARCEL SIZE F3 l� LAND USE APPLICATION# OWNER NAME C { -� fi t C• C_LC-TC' PHONE OWNER ADDRESS i CITY/STATE/ZIP CONTRACTOR _ yyy�Pf PHONE CONTRACTOR ADDRESS ;-I- CITY/STATE/ZIP 7y' �j rj�- SUBCONTRACTOR �+R?�_ PHONE •lel SUBCONTRACTOR ADDRESS_ �4� I Y� c51 1"v t 4ve. CITY/S TATE/ZIP WATSS Lcg± n7 LICENSE C•57 ❑C-61 ❑D-09 ❑Other NUMBER t/66 G EXPIRATION DATE L�� ]��I GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ronge Section ' INTENDED USE 17 Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System M If different from Owner: ater ystem arae Contact Name or Phom Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other c ❑Monitoring Well(s) #of wells ❑Soil Boring(s) a of borings PI(Geotechnical #of borings ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Re lacement ❑Pump Repair WELL CONSTRUCTION Drilling Method Mud Rotary ❑Air Rotary 13 Auger 13 Cable Tool ❑Push Point 13 Other Proposed Well Depth ( ft Excavation_ in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter �\ ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft Neat Cement(941b bag I5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(200/.solids) ❑Manufacturer Spec%solids % Name _ ❑Specs on File ❑Specs Submitted Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 13Driller D Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width P Length _ft Thick in ❑Christy Box ❑Stove Pipe C PUMP ❑Submersible ❑Turbine ❑Other HP_ Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. J ��HOUR ADVANCE NOTICE REeQrUIRED F IOR INSPECTIONSSIGNED TITLE c�F1� vp(,);,f r DATEgim Al r�000'0 L� 1 .�u 3iiii:jfw iii�iiiiir3i-"---• 4 u, nra� r�yg y °nx<s-_ .i:alta: /'193 •sr:mte .r ;��:,........�................... .............—_....e.e... ,.,.,...., ...:v:.E,.E€.€E.E,.i" .�]eame�- ..,.ri!.€e v€E;le: :E€';' El,l ......... .....................».."...........€., .,. 'i.i:':. a �.' :::(:?Eti.; v'tl�l�x,ii?Pi";.....--«'-'.'.•`.'�l=.=li")':°Sljlitir't&`::. .�.r.._�....., s€:'::::......::.:,..€t. _.�..,r�,..::•.......i.:,.....:::.,,.iE,;,::;:W� °^§Yiiie[ tc':::.;a:::"r:r�� _ 1• ..........._ri.,;„ ......,., .>...............€ €.._..,,_....E',€ef ..,.,., 3..:�a�E'.. ...l.: r'IfE€... ..,r �.. ,..nXn a:..... 'R.•4 ash.. � rnfiwl� tr y DEPARTMENT USE ONLY A plication Accepted By �` Date ff� Area Employe Y �F�t f� _ cnut Li pection P,y .' ��. �� Dated ❑ SPECIAL Well PermitR Pump Inspection By Date ❑ WAIVER Received APR Constructed Well Depth ft 1 _ SAN JOAQUIN COUNTY COMMENTS_` 3Cv1�f SC .tl. CIL- _. Gt'1 ENV1ROiV`gEN7Al /�W — [H JT }S` r"2- asl C ?/'.�f� C '7��- �Ca.t� 'F�;-6� bEPARTMENT PE SC Received Chec Amount Date P Invoice# Well ID# Codes Info B Cash emitted ervl CB7 Sao 53 S(0 Crr_i' Sllarfi3 �`cJ�� c _ ry-r 'lc�' ' /ice EHD 43052-046 1!27l2405 WELL PUbriP PERMIT